10 Heterosexuality

Chapter 10: Heterosexuality

Emma is a working class nursing trainee in her early twenties. She seeks help because she has been finding sex with her boyfriend to be painful and unpleasant because her vaginal muscles tense up so much. She is scared of losing her relationship and continues to have sex even though it is causing her distress. She doesn’t feel able to talk to her friends or her mum about the problem as she’s worried that there is “something wrong with her”. It’s not something she’s ever read about in the magazines that she enjoys which tend to present sex as a fun and easy activity.

Think about

• What is your formulation/understanding of the key issues for Emma?
• What assumptions might you have about Emma’s relationship on the basis of this information and your training?
• How would you proceed?

It would be useful to explore Emma’s expectations and assumptions about both heterosexual sex and heterosexual relationships. For example, we can see from her presentation that she thinks that she must provide regular sex in order to keep a partner; that this sex has to involve her vagina being penetrated; that it is up to her to keep her partner once she has him by continuing to be desirable; and that the relationship should be private and seem perfect to other people in her life.

Common interventions for the ‘sexual dysfunctions’ such as this one involve ruling out medical problems (such as urinary tract infections or sexually transmitted infections) and then working with the client towards a goal of penetration, for example, by introducing fingers/dilators of increasing size into the vagina in cases such as this. A limitation of such an approach is that it perpetuates the idea that penetration is necessary for satisfactory sex. It also fails to address the issues around Emma feeling that she has to be a certain way in order to keep her partner. Sex therapy with heterosexual couples may usefully apply the common sensate focus type practices which aim to take the pressure off penetration and orgasm, and focus on people learning to enjoy the here-and-now of each sensation. In addition to this, it is useful for heterosexual clients experiencing sexual issues to learn how to tune into their own desires and communicate these to partners, for example by creating yes, no, maybe lists of all possible sexual activities they can think of, and whether or not they would like to try engaging in these, and then comparing these.

It is also useful to broaden out explorations with clients like Emma, as sexual experiences are often reflective of wider issues. For example, many young women feel that they have to be a certain way in order to be accepted by potential partners and by others in their lives (e.g. attractive, nice, passive – see chapter 4).

You can find a more detailed case study of a client with a similar constellation of issues in: Barker, M. (2011). De Beauvoir, Bridget Jones’ Pants and Vaginismus. Existential Analysis, 22 (2), 203-216.